1 Clinical examination of psychiatric

patient (psychiatry assessment)

A. Psychiatric History

B. Metal Status Examination

By. Lulu A. (MSc in psychiatry) 1

 Objectives of this topics
At the end of the course, students will be able to:
1) Understand interviewing techniques
2) Develop important interview skills

3) Demonstrate effective psychiatric assessment

4) Apply therapeutic communication in psychiatric patient care
5) Demonstrate approach to psychiatric Pts. & apply proper history taking and MES in
day to day clinical experience
6) Identify components of psychiatric assessment
7) Implement components of psychiatric assessment
2
Teaching-Learning Methods
 Interactive lecture
 Small group discussion
 Role play
 Case study
 Video show
 Demonstration
 Seminar presentation
 Brain storming

3
Methods of assessment
 Formative
 Oral questioning
 Case study
 Summative (Percentage)
 Seminar 10%
 Assignment 10%
 Test:20%
 Quiz 10%
 Objectively written exam
 Final exam 50
4
Teaching-Learning Materials
Reference Books
1) Barbara Bates (1995), a guide to physical examination and history taking.
2) . Fente Ambaw Lecture note on Health assessment for health science students
3) Kaplan &Sadock’s Comprehensive Text book of Psychiatry (2015, 11th edit.)
4) Basic concepts of Psychiatric-mental health nursing (1998, 4th edit.)
5) Diagnostics and Statistical Manual of mental disorders (2013, 5th edit)
6) Mental health-psychiatric nursing (1988, 2nd edit.)
7) KAPLAN & SADOCK’S Synopsis of Psychiatry Behavioral Sciences/Clinical
Psychiatry ELEVENTH EDITION
8) Kaplan & Sadock’s Comprehensive Text book of Psychiatry (2000, 7th edit.)

5
Purpose of The Psychiatric Interview
 Psy. Ineter. is the most important element in the evaluation and
care of persons with mental illness

 A major purpose of the initial psy. Inter. is to obtain information that

will establish a criteria-based diagnosis according to (DSM-5)

 This process, helpful in the prediction of the course of the illness

and the prognosis, leads to treatment decisions

6
Purpose of The Psychiatric Interview…
 A well-conducted psychiatric interview results in a multidimensional
understanding of the biopsychosocial elements of the disorder and
provides the information necessary for the psychiatrist, in
collaboration with the patient, to develop a person-centered treatment
plan.
 Equally important, the interview itself is often an essential part of the treatment
process.

7
General Principles of psychiatric assessment
 Agreement as to Process
 Privacy and Confidentiality
 Respect and Consideration
 Rapport/Empathy
 Patient–Physician Relationship
 Safety and Comfort
 Conscious/Unconscious
 Person-Centered and Disorder-Based Interviews
 Time and Number of Sessions

8
Agreement as to Process
 To establish agreement, at the beginning of the interview the clinician should
introduce himself or herself and, depending on the circumstances, may need
to identify why he or she is speaking with the patient.
 consent to proceed with the interview should be obtained and the nature of the
interaction should be stated
 The patient should be encouraged to identify any elements of the process that he
or she wishes to alter or add

9
Agreement as to Process…

 Is patient -seeking the evaluation on a voluntary basis or has been

brought involuntarily for the assessment ?

 this information will guide the interviewer especially in the early

stages of the process.

10
Privacy and Confidentiality

 Confidentiality is crucial in the evaluation/treatment process

 may need to be discussed on multiple occasions .

 Confidentiality is an essential component of the patient–

clinician relationship
 Sometimes, in a hospital unit or other institutional setting,
this may be difficult
11
Privacy and Confidentiality…
 at the beginning, the interviewer should indicate that the content of
the session(s) will remain confidential except for what needs to be
shared with the referring physician or treatment team

 Some evaluations, including forensic and disability evaluations, are

less confidential and what is discussed may be shared with others
 In those cases, the interviewer should be explicit in stating that the
session is not confidential and identify who will receive a report of
the evaluation
12
Privacy and Confidentiality…
 If a family member wishes to talk to the clinician, it is
generally preferable to meet with the family member(s) and
the patient together at the conclusion of the session and
after the patient’s consent has been obtained.

 The clinician should not bring up material the patient has

shared but listen to the input from family members and
discuss items that the patient introduces during the joint
session
13
Privacy and Confidentiality…
 Occasionally, when family members have not asked to be seen, the
clinician may feel that including a family member or caregiver
might be helpful and raise this subject with the patient

 This may be the case when the patient is not able to communicate
effectively
 As always, the patient must give consent except if the psychiatrist
determines that the patient is a danger to himself or herself or others

14
Privacy and Confidentiality…
 In educational and, occasionally, forensic settings, there may be
occasions when the session is recorded
 The patient must be fully informed about the recording and how the
recording will be used.
 The length of time the recording will be kept and how access to it will
be restricted must be discussed.
 Occasionally in educational settings, one-way mirrors may be used as
a tool to allow trainees to benefit from the observation of an
interview.

15
 Respect and Consideration
 the Pt. must be treated with respect, & clinician should be considerate the
circumstances of the patient’s condition such as

 Pt experiencing considerable pain or other distress and frequently is feeling

vulnerable and uncertain of what may happen
 B/c of the stigma of mental illness and misconceptions about psychiatry, the
patient may be especially concerned, or even frightened, about seeing a psychiatrist
 skilled clinician is aware of these potential issues and interacts in a manner to decrease,
or at least not increase, the distress.
 The success of the initial interview will often depend on the physician’s ability to
allay/alleviate excessive anxiety
 Rapport/Empathy
 In the clinical setting, rapport can be defined as the harmonious responsiveness of
the physician to the patient and the patient to the physician
 Empathy is understanding what the patient is thinking and feeling and it occurs when
the clinician is able to put himself or herself in the patient’s place while at the same time
maintaining objectivity
 Respect for and consideration of the patient will contribute to the development of
rapport
 Empathic interventions
 (“That must have been very difficult for you” or
 “I’m beginning to understand how awful that felt”)
 further increase the rapport
17
Action s or behaviors those promote empathy
 Head nodding
 putting down one’s pen
 leaning toward the patient
 or a brief comment,
 “I see,”
 can accomplish this objective and simultaneously indicate that
this is important material.

18
Patient–Physician Relationship

 This is the core of the practice of medicine

 The Rx should always be Pt centered
 relationship b/n any one pt and clinician will vary depending on each of
their personalities and past experiences as well as the setting and purpose
of the encounter
 there are general principles that, when followed, help to ensure that the
relationship established is helpful
 nonjudgmental attitude and behavior of the physician –will reinforce pt’s sharing of his /her problem
Conscious/Unconscious
 In order to understand more fully the pt –physician relationship,
unconscious processes must be considered
 majority of mental activity remains outside of conscious awareness
 In the interview, unconscious processes may be suggested by
 tangential references to an issue
 slips of the tongue or mannerisms of speech, what is not said or avoided, and

 other defense mechanisms

 Conscious/Unconscious
 In the interview, transference and counter transference are very
significant expressions of unconscious processes

 Transference is the process of the pt unconsciously and inappropriately

displacing onto individuals in his or her current life those patterns of
behavior and emotional reactions that originated with significant figures
from earlier in life, often childhood

21
 In the clinical situation the displacement is onto the psychiatrist, who
is often an authority figure or a parent surrogate.

 countertransference is the process where the physician unconsciously

displaces onto the patient patterns ,of behaviors or emotional
reactions as if he or she were a significant figure from earlier in the
physician’s life

22
 Person-Centered & Disorder-Based Interviews

 A psychiatric interview should be person (patient) centered

 That is, the focus should be on understanding the patient and enabling the
patient to tell his or her story

 The individuality of the patient’s experience is a central theme, and the

patient’s life history is elicited, subject to the constraints of time, the
patient’s willingness to share some of this material, and the skill of the
interviewer.
Person-Centered & Disorder-Based Interviews…
 A person-centered approach focuses on strengths and assets as well as
deficits

 “Tell me about some of the things you do best,” or,

 “What do you consider your greatest asset?”
 A more open-ended question, such as, “Tell me about yourself,” may
elicit information that focuses more on either strengths or deficits
depending on a number of factors including the patient’s mood and
self-image
24
 Safety and Comfort
 Both the patient and the interviewer must feel safe, this includes physical
safety

 Patients, especially if psychotic or confused, may feel threatened and need to be

reassured that they are safe and the staff will do everything possible to ensure their
safety

 The interview may need to be shortened or quickly terminated if the patient becomes
more agitated and threatening
 Time and Number of Sessions

 For an initial interview, 45 to 90 minutes is generally allotted.

 For inpatients on a medical unit or at times for pts.who are confused, in
considerable distress, or psychotic, the length of time that can be tolerated
in one sitting may be 20 to 30 minutes or less.
 In those instances, a number of brief sessions may be necessary
 Even for pts. who can tolerate longer sessions, more than one session
may be necessary to complete an evaluation
Time and Number of Sessions…
 The clinician must accept the reality that the history obtained is never
complete or fully accurate

 An interview is dynamic and some aspects of the evaluation are

ongoing, such as how a patient responds to exploration and
consideration of new material that emerges

27
The Interview Room

 should be relatively soundproof

 The decor should be pleasant and not distracting
 If feasible, it is a good idea to give the patient the choice of a soft chair or a hard-
back chair.
 Sometimes the choice of the chair or how the chair is chosen can reveal
characteristics of the patient
 psychiatrists suggest that the interviewer’s chair and the patient’s chair be of
relatively equal height so that the interviewer does not tower over the patient (or
vice versa).
 the patient and the psychiatrist should be seated approximately 4 to 6 feet apart
 The psychiatrist should not be seated behind a desk.
 The psychiatrist should dress professionally and be well groomed.
 General characteristics

 Detailed Hx.
 In psychiatry a very good psychiatric interview is
the single most important method of arriving to
Dx.
 i.e. Clinicians skillful psychiatric interview is the single most important
method in order to Dx psychiatric disorders

29
A. Psychiatric History
(Assessment)
30
Psychiatric history…

 Psychiatric history is the record of the patient's life

 It allows to understand:
 Who the patient is

 Where the patient has come from

 Where the patient is likely to go in the future

31
Psychiatric history…
 It includes information about the patient obtained from other
sources (collaterals):
 Parent, Spouse, Colleagues

 Not very different from assessment in general medicine &

More emphasis is given to history
 Few special investigations to reach at the diagnosis

32
Interviewing Technique
 Provide privacy & no interruption.
 Seats arranged diagonally and of equal level.
 Both the health professional and the patient should have access
to exits
 Usually 30min to one hour (average 50min)
 For an initial interview, 45 to 90 minutes is generally allotted

33
Interviewing Technique…

Welcome the patient in a calmly and politely manner

Introduce yourselves by name

Explain in a simple language:

 The purpose of the interview &

 level of confidentiality he/she can expect

34
Interviewing Technique…
 Begin with open ended questions
 Let the patient speak about the problems for the first few minutes
without interrupting
 Observe the patient’s behavior
 Ask specific closed ended questions later
 Ask the pt if s/he has something to say before wrapping up the
interview
 Explain in plain language the clinical problem & the treatment plan
35
Important Interviewing Technique
 Maintaining good eye contact
 Adopting a relaxed posture
 Using facilitator utterances and gestures
 Detecting verbal and non verbal cues
 Avoid premature false reassurance of the patient
 Avoid Normalizing the patient’s experience
 Avoid Impatience during the interview
 Avoid Appearing inattentive during the interview
36
Major components of initial psychiatric
interviews –based on DSM-5
1) Identification
9) Developmental & social history
2) Source &reliability of
10) Review of system
information
11) Mental status Examination
3) Chief complaints 12) physical examination
4) History of presenting illness 13) formulation
5) Past psychiatric history 14) DSM-5 Diagnosis
6) Substance use /abuse 15) Treatment Plan
7) Past medical history
8) Family history
37
I. Identification
 Provide a succinct/consice demographic summary of
the patient by
 Name, age, sex, marital status

 Ethnic background, religion, address

 Educational status, occupation, language
 Patient's current living circumstances
38
Id…
 Whether the patient came
 On his or her own
 Referred by someone else
 Brought in by someone else
 Accompanied by
 Visit/ is it the first episode (Previous admissions to a hospital for the
same or a different condition)

39
Id…
 The identifying data are meant to provide important patient
characteristics that may affect:
 Diagnosis
 prognosis
 treatment and
 compliance

40
E.g.

 E.g. Mr. Z is a 25-year-old single male , Amhara, Protestant ,who

works as a department store clerk. He is a college graduate living with
his parents in Dilla Town. He was referred to psy. Opd by his internist
for psychiatric evaluation
 This is the first psychiatric hospital admission for Mr. A., a 21-year-old
single male employed part-time as a veterinarian's assistant. He
currently lives with his mother and has never been married.

41
 II. Source and Reliability

 It is important to clarify where the information has come from, especially

if others have provided information or records reviewed, and the
interviewer’s assessment of how reliable the data are.

42
 III. Chief Complaint
 This should be the patient’s presenting complaint, ideally in his or her own
words.
 What do you think is your main problem?

 What brought you to the hospital?

43
 II. Chief Complaints…
 A verbatim recording of the patient's reason for seeking help.

Examples include
 “I’m depressed” or “I have a lot of anxiety.
 I am thinking to kill myself”
 “I am not sick, it is my wife who is sick!”
 the patient is mute
44
 Example - c/c from patient
“I’m depressed” or “I have a lot of anxiety.

“I am thinking to kill myself” for 3 weeks of duration

45
 III. History of presenting illness (HPI):
 HPI is a chronological description of how symptoms in the current
episode have unfolded/revealed over time
 Most important part in making a diagnosis!
 Take a detailed account of the illness from the earliest time at which a
change was noted until consultation.

46
HPI…

 The essential questions to be answered in the history of the present

illness include
 what (symptoms)
 how much (severity)

 How long (duration of illness) , and associated factors.

47
HPI…
 Onset of symptoms (When did the problem start?)
 How the symptom emerged/How did it develop? (abrupt, insidious)
 Sign an symptoms Progression over time
 Characterization of symptoms
 Triggers: Aggravating and ameliorating factors
 What triggered the current episode?
 Effect of symptoms on functioning (Severity): associated
impairment due to illness (physical, psychological & social)---
Impact of illness 48
HPI…
 Treatments sought and its effects on the symptoms
 Adherence to treatments
 Risk of danger to self and others!
 Are there psychophysiological symptoms? (location, intensity,
and fluctuation)

49
HPI…
 a psychiatric review of systems in conjunction with the history of the
present illness to help rule in or out psychiatric diagnoses with
pertinent positives and negatives.
 Pertinent positive and negative findings
MAPSO — mood, anxiety, psychosis, suicide and substance & other
 This review can be split into four major categories of mood, anxiety,
psychosis, and other

50
 Psychiatric Review of Systems includes:-
Mood
 Depression symptoms: - sadness ,Tearfulness, sleep appetite, energy,
concentration , sexual function, guilt , psychomotor agitation or
retardation ,interest. A common pneumonic used to remember the
symptoms of major depression is SIGECAPS (sleep ,interest , guilt ,
energy concentration , appetite , psychomotor agitation or slowing ,
51
sicidality )
HPI..

 Mania : - impulsivity , grandiosity , recklessness , excessive energy ,

decreased need for sleep , increased spending beyond means ,
talkativeness , racing thoughts ,hyper sexuality
 Mixed/ or other :- irritability , liability
Anxiety -
 GAD symptoms: - where , when , who, how long , how frequent

52
 HPI…

 Panic disorder symptom- how long until peak ,somatic symptoms

including racing heart , sweating shortness of breathing , trouble
swallowing , sense of doom ,agoraphobia, recurrence
 Obsessive compulsive symptoms – checking , cleaning , counting ,
organizing
 PTSD Symptoms –night mares , flash backs ,startle response , avoidance

53
 Social anxiety symptoms
 Simple phobias –eg, heights , planes spiders and etc
Psychosis
 Hallucination - auditory , visual , tactile, olfactory
 Paranoia
 Delusions - TV , radio , thought broad casting , mind control , referential
thinking
 Patients perception – reality testing
 Others : -
54
IV. Past Psychiatric History
 Description previous episodes ( patient's symptoms )-Dx, Rx and
response
 Previous admission, names of hospitals and length of each illness,
 Extent of incapacity (status of functionality) and Inter-episodic
Functioning
 Previous medications: dose, duration, efficacy and side effects
 Effects of previous treatments (time patient felt completely well?)
 Degree of compliance /chronologically.
 Past suicidal/homicidal history, Substance history
55
 VI. Substance Use, Abuse, and Addictions

 A careful review of substance use, abuse, and addictions is essential to

the psychiatric interview.
 a nonjudgmental style will elicit more accurate information.

 specific questions for reluctant pts

 (e.g., “Have you ever used marijuana?” or “Do you typically drink alcohol
every day?”).

56
 VI. Substance Use, Abuse, and Addictions…

 History of use should include which substances have been used, including
 Alcohol
 drugs

 medications (prescribed or not prescribed to the patient), and

 routes of use (oral, snorting, or intravenous).

 The frequency and amount /dose of use should be determined

57
 Substance Use, Abuse, and Addictions…

 The definition of alcohol may be misunderstood, for example,

 “No, I don’t use alcohol,” yet later in the same interview,
 “I drink a fair amount of beer.”
 Also the amount of alcohol can be confused with the volume of the drink:
 “I’m not worried about my alcohol use.
 I mix my own drinks and I add a lot of water.”

58
 Substance Use, Abuse, and Addictions…

 In response to a follow-up question, “How much bourbon? Probably three

or four shots?”
 Tolerance, the need for increasing amounts of use, and any withdrawal
symptoms should be established to help determine abuse versus
dependence.
 Impact of use on

59
Substance Use, Abuse, and Addictions…
 social interactions
 work
 school
 legal consequences
 and driving while intoxicated (DWI) should be covered

 Some psychiatrists use a brief standardized questionnaire, the CAGE

or RAPS4, to identify alcohol abuse or dependence.

60
Substance Use, Abuse, and Addictions…

 CAGE includes four questions:

 C- Have you ever Cut down on your drinking?

 A- Have people Annoyed you by criticizing your drinking?

 G- Have you ever felt bad or Guilty about your drinking?
 E- Have you ever had a drink the first thing in the morning, as an
Eye-opener, to steady your nerves or get rid of a hangover?
61
Substance Use, Abuse, and Addictions…

 The Rapid Alcohol Problem Screen 4 (RAPS4) also consists of four

questions:
 Have you ever felt guilty after drinking (Remorse)?
 Could not remember things said or did after drinking (Amnesia)?

 failed to do what was normally expected after drinking (Perform) ? or

 Had a morning drink (Starter)?

62
 Substance Use, Abuse, and Addictions…
 The patient’s readiness for change should be determined by identifying whether they are
in the
 Precontemplative phase
 Contemplative phase , or

 Action phase.
 Referral to the appropriate treatment setting should be considered
 important substances and addictions that should be covered
63
 Substance Use, Abuse, and Addictions…

 Tobacco and caffeine use, gambling, eating behaviors, and Internet use.  
 Gambling history should include casino visits, horse racing, lottery and
scratch cards, and sports betting.
 Addictive type eating may include binge eating disorder.

64
V. Past medical history
 Obtain a medical review of symptoms
 Major medical or surgical illnesses and
 Major traumas particularly those requiring
hospitalization.
 Medications (in the past/taken regularly/allergic hx?)
 Episodes of craniocerebral trauma, neurological
illness & tumors
65
 V. Past medical history …
 Assessing past medical hx is important b/c
 Medical illnesses can precipitate a psychiatric disorder (e.g., anxiety
disorder in an individual recently diagnosed with cancer),
 medical illness mimic a psychiatric disorder (hyperthyroidism
resembling an anxiety disorder),
 Medical illness can be precipitated by a psychiatric disorder or its treatment
(metabolic syndrome in a patient on a second-generation antipsychotic
medication), or influence the choice of treatment of a psychiatric disorder (renal
disorder and the use of lithium carbonate).

66
 Past medical history …

 In women, a reproductive and menstrual history is important as well as a

careful assessment of potential for current or future pregnancy.
 (“How do you know you are not pregnant?” may be answered with
“Because I have had my tubes tied” or “I just hope I’m not.”)
 A careful review of all current medications is very important.

67
Past medical history…
 presence of a seizure disorder
 History of testing positive for HIV
 Episodes of loss of consciousness
 Changes in usual headache patterns
 Changes in vision, and
 Episodes of confusion and disorientation
 History of infection with syphilis

68
VI. Family history
 Hx of psychiatric illness, hospitalization & treatment of the
patient's immediate family members.
 Family history of suicide, antisocial or aggressive behavior
 Family history of alcohol and other substance abuse
 Who is available to support the patient
 Who is exacerbating symptoms
69
Family history …
 Family's attitude toward, and insight into, the patient's
illness (supportive, indifferent, or destructive?)
 Patient's attitude toward each of his parents and siblings
 Family income & difficulties in obtaining it
 Impact of illness on the family
 Family history of seizure disorder

70
 Developmental and Social History
 Developmental and social history include detail description of patients

 Personal History
 Forensic History:

 Sexual History
 Premorbid personality (traits)

71
Developmental and Social History …
Personal history
this is detail description of patients
A. Prenatal and perinatal history
B. Infancy and early childhood (birth through age 3) history
C. Middle childhood (age 3- 11) history
D. Late childhood puberty through adolescence history
E. Adulthood history

72
Personal History …
1. Prenatal and perinatal
 Was pregnancy planned and wanted
 Full-term pregnancy or premature
 Vaginal delivery or caesarian
 Mother's emotional and physical state at the time of the pt's birth?
 maternal health problems during pregnancy?
 Drugs taken during pregnancy (prescription and recreational)
 Birth complications
73
Personal History …
2. Infancy and early childhood (0-3yrs)
 Infant-mother relationship
 Problems with feeding and sleep
 Unusual behaviours (e.g., head-banging, rocking)
 Was the child shy, restless, overactive, withdrawn, out going, friendly?
 Significant milestones
 Standing/walking
 First words/two-word sentences
 Bowel and bladder control
74
Personal History …
3. Middle childhood (3-11yrs)
 Preschool and school experiences
 Tolerance to separation from caregivers
 Number & closeness of the patient's friends/play
 Methods of discipline & punishments
 Major Illness, surgery, or trauma
 Temperament, aggression, phobias, bed-wetting, etc.
 Learning disabilities

75
Personal History …

4. Late childhood (puberty through adolescence)

 Onset of puberty & Academic achievement (r/ship with teachers )
 Organized activities (sports, clubs)
 Areas of special interest
 Romantic involvements and sexual experience
 Work experience
 Experimentation with drugs (alcohol, illicit drugs…)
 Symptoms (moodiness, irregularity of sleeping/eating,
fights/arguments) 76
Personal History …
5. Young adulthood
 Meaningful long-term relationships
 Academic and career decisions
 Military History, behavior problems, premature discharge, etc
 Work history (Summary of the jobs held, the length of time in
each, and the reasons for leaving)
 Interference of psychiatric illness with the capacity for
sustained productive work.
 Intellectual pursuits and leisure activities 77
Personal History …

6. Middle adulthood and old age

 Changing family constellation
 Social activities
 Work and career changes
 Major losses
 Retirement and aging

78
Forensic History:
 Legal difficulties, imprisonment/prison history
 List of offences/charges & legal outcomes

 History of being in trouble with the police?

 Ever been arrested and for what? How many times?
 Hx of assault/violent/sexual crimes and persistent offending, weapons?
 Attitude toward the arrests or prison terms?
79
Sexual History
 Developmental
 Onset of puberty/menarche
 Development of sexual identity and orientation
 First sexual experiences
 Attitudes toward sex (shy, timid, aggressive?)
 Have you noticed any changes or problems with sex recently?
 patient needs to impress others and boast of sexual conquests?
 patient experience anxiety in the sexual setting?
 Was there promiscuity?
80
Sexual dysfunctions

 Desire phase
 Excitement phase

 Organic phase
 Resolution phase

81
Desire phase

 Presence of sexual thoughts or fantasies

When do they occur and what is their object?
Who initiates sex and how?
Excitement phase
Difficulty in sexual arousal (achieving or maintaining erections,
lubrication), during foreplay and preceding orgasm

82
Orgasm phase

 Does orgasm occur?

 Does it occur too soon or too late?

 How often and under what circumstances does orgasm occur?

83
 If orgasm does not occur, is it because of not being excited or lack
of orgasm despite being aroused?

Resolution phase
What happens after sex is over (e.g., contentment, frustration,
continued arousal)?

84
 Premorbid personality (traits)
• What is personality?
• personality refers to individual differences in characteristic pattern of
thinking ,feeling and behaving
 An enduring pattern of inner experience and behavior that manifests in
two or more of the following:
– cognition (i.e., ways of perceiving and interpreting self and others);

– Affectivity (i.e., range, intensity, lability)

– Interpersonal functioning; Impulse control 85

Premorbid personality (traits)…
 How was patients personality before he got sick?
 How would you describe yourself?
 How would other people describe you?
 When you find yourself in difficult situations, what do you do to cope?
 What sort of things do you like to do to relax?
 Do you have any hobbies? (Fantasies & dreams, Values)
 Do you like to be around other people or do you prefer your own
company?
86
 X. Review of Systems
 The review of systems attempts to capture any current physical or
psychological signs and symptoms not already identified in the present
illness.
 Particular attention is paid to neurological and systemic symptoms (e.g.,
fatigue or weakness).
 Illnesses that might contribute to the presenting complaints or influence the
choice of therapeutic agents should be carefully considered (e.g., endocrine,
hepatic, or renal disorders).
 Generally, the review of systems is organized by the major systems of the
body.
87
XI. Mental Status Examination (MSE)
 (MSE) is the psychiatric equivalent of the physical examination in the
rest of medicine
 MSE explores all the areas of mental functioning and denotes evidence of
signs and symptoms of mental illnesses

 Data are gathered for the MSE throughout the interview from the initial
moments of the interaction, including what the patient is wearing and
their general presentation

88
 The MSE gives the clinician a snapshot of the patient’s mental status
at the time of the interview and is useful for subsequent visits to
compare and monitor changes over time

 physician must also be as objective as possible in making mental status

observations
 Observed data are always more reliable than inferred data

89
 Appearance and Behavior
 general description of how the patient looks and acts during the interview

 Does the patient appear to be his or her stated age, younger or older?

 Is this related to the patient’s style of dress, physical features, or style of

interaction?
 Items to be noted include what the patient is wearing, including body
jewelry, and whether it is appropriate for the context

90
 Is the patient overdressed or underdressed?
 Is the patient wearing excessive, garish make-up?
 Is the patient disheveled, unkempt, or ungroomed?

 Is the patient cooperative, oppositional, hostile, seductive, or impassive?

 Are there unusual movements?
 Is the patient making smacking or chewing motions?

 Is there a tremor?
 Is the patient pacing? 91
 Motor Activity
 may be described as normal, slowed (bradykinesia), or agitated
(hyperkinesia)

 This can give clues to diagnoses (e.g., depression vs. mania) as well as
confounding neurological or medical issues

 Gait, freedom of movement, any unusual or sustained postures, pacing,

and hand wringing are described
 The presence or absence of any tics should be noted, as should be jitteriness, tremor, apparent restlessness, lip-
smacking, and tongue protrusions

92
 Motor Activity…
 These can be clues to adverse reactions or side effects of medications such
as
 tardive dyskinesia
 akathisia, or
 parkinsonian
 features from antipsychotic medications or suggestion of symptoms of
illnesses such as attention-deficit/hyperactivity disorder

93
 Speech
 Elements considered include fluency, amount, rate, tone, and volume
 The speech section of the MSE describes the physical production of speech, not the
ideas being conveyed.
 Observations may be made about volume, rate, spontaneity, syntax, and vocabulary.
 Any speech abnormality such as dysarthria or aphasia is described.
 The speech of a manic patient may be loud and pressured.
 Conversely, the speech of a depressed patient may be soft and hesitant.

94
For example

 He speaks spontaneously and very rapidly, becoming pressured at

times, but he is interruptible. Volume is occasionally loud. Rhythm
and expressive intonation are normal. Speech is understandable, but
some words are poorly articulated because of the high rate of
speech production.

95
96